Ultrasound
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A patient born with only one testicle can present unique issues. Utilizing your point-of-care ultrasound is key to a correct diagnosis.

It’s a busy Monday morning, and you watch as a new patient awkwardly limps onto your only open bed. You immediately wonder what is causing him to walk with such a strange gait. After Glancing at the EMR, you find a helpful hint in the nurse’s note about his chief complaint — testicular pain.

Your patient is a 38-year-old male who presents with a five-day history of right- sided testicular pain, redness, and swelling. You suppress your first set of inappropriate questions (“Five days? Really? What took you so long to come in?”) and proceed with introducing yourself to the patient and his wife. The patient tells you that the symptoms began spontaneously five days ago. He initially had intermittent pain but, by day three,  it had became constant, followed by swelling, and finally redness, which started that morning. He denies any fever, abdominal pain, vomiting or diarrhea. He denies penile discharge or urinary frequency. His wife agrees that they have been monogamous for their 10 years of marriage. They deny any exacerbating or relieving events, and this is the first time he says he has ever had any pain like this.

The patient’s vital signs are all within normal limits, including a temperature of 98.6 degrees. His exam reveals a swollen, indurated, erythematous, and tender right testicle. Due to the amount of swelling and induration, a left testicle is not palpable in the scrotum or inguinal canal. The remainder of the exam is essentially normal, including a completely soft and non-tender abdominal exam.

In disbelief of the exam findings, you question the patient to make sure that your testicular count matches his. He admits that he was “born with only one testicle” and that he has never had his condition evaluated. You have your nurse place a peripheral IV and order a CBC, CMP, pT/pTT, urinalysis, and IV pain medications. As the IV pain medications are being administered, you place your patient in a comfortable position to perform a point-of-care testicular ultrasound. The following images are obtained (Images 1 and 2). What do you see? What is your plan?

What do you see? What is your plan?

ultrasound-image-1

ultrasound-image-2

The patient’s point-of care-testicular ultrasound demonstrates only one testicle in the scrotal sac. It is heterogeneous and enlarged on ultrasound and there is minimal flow to it with application of power Doppler. You see a small flash of color surrounding the testicle but none within the actual testicle on ultrasound. The testicle appears heterogenous on ultrasound and there is a rim of hypoechoic (black) fluid just inferior to the testicle signifying surrounding edema. Compare your images to a normal set of testicles obtained with your probe centered along the median raphe (pictured).

You are concerned that your patient has testicular torsion and decide that manual detorsion will likely be unsuccessful given that he has had symptoms for five days. Urology was consulted immediately after the bedside ultrasound and the patient was taken to the operating room within an hour of presentation to the ED. Intraoperatively, the testicle was described as purple, black, and ischemic. The heterogeneous regions seen on ultrasound were necrotic tissue requiring a total orchiectomy. The patient’s second testicle was not found in the scrotum, inguinal canal, or abdomen. Following his right total orchiectomy, the patient was observed for 24 hours and then discharged home with his wife without any complications.

ultrasound-illus

ultrasound-image-3

 

Pearls & Pitfalls for Using Point-of-Care Ultrasound
to Diagnose Testicular Torsion

1- Reviewing the Anatomy: The median raphe is the external mark of the division between the left and right scrotum. Inside the scrotum, the superficial fascia is an incomplete septum, which separates the left and right testicle. The tunica vaginalis consists of a visceral layer adherent to the testicle and a parietal layer separated by a small amount of fluid. Typically, this small amount of fluid is not prominently seen on ultrasound. Remember that the spermatic cord consists of the vas deferens, genitofemoral nerve, pampiniform venous plexus, testicular artery, cremasteric artery, and deferential artery. The testicular arteries supply the scrotal contents. On ultrasound, branches of the testicular artery should be seen within the testicular tissue.1

2- Performing a testicular US: Begin the testicular ultrasound with the patient in the supine position, knees flexed, and hips externally rotated. The scrotum should be supported by a towel to allow easy visualization of the testicles. A linear array, high frequency transducer (5-10 MHz) should be used. Begin the scan on the unaffected testicle to ease patient comfort and to provide a “normal” exam for comparison to the affected side. Exam of the testicle should include views from two planes, both longitudinal and transverse. The normal adult testicle measures 4 x 3 x 2.5 cm, is homogenous in texture, and has a medium echotexture.2 Blood flow must be assessed to evaluate perfusion of the testicle. Apply Doppler systematically over the testicle and assess for flow. Color and power Doppler have a sensitivity of 86% and a specificity of 100% for diagnosing testicular torsion.3 Use Power Doppler in situations where you are concerned about low flow states.

3- Diagnosing Testicular Torsion: Testicular torsion occurs most commonly in males under 20 years of age, however, it can occur at any age.4,5 Patients with acute torsion usually present with sudden onset of pain which can be associated with nausea, vomiting, and even fever. There are two types of torsion which are differentiated based on their pathophysiology. Intravaginal torsion results from the “Bell-Clapper deformity”, which is an abnormally superior attachment of the tunica vaginalis on the testicle. This allows the tunica vaginalis to encircle not only the testicle, but also the epididymis and the distal spermatic cord. The result is increased rotational mobility of the testicle within the scrotum. This deformity has a 12% prevalence and is present bilaterally 40-80% of the time.1,6,7 Extravaginal torsion occurs in undescended testicles, which lack fixation to the tunica vaginalis, and therefore have increased rotational mobility. Testicular torsion is more likely to occur in a patient with an undescended testicle.8

4- Management for Testicular Torsion: Salvage of the testicle depends on the duration of ischemia. Rates of salvage approach 100% if intervention is within 6 hours of onset of symptoms. This rate decreases to 70% for intervention in 6-12 hours, and 20% in 12-24 hours.9 Definitive management of testicular torsion is surgical management. Manual detorsion can be attempted by rotating the affected testicle from medial to lateral (“Open the Book”), however this technique has varied success and not all torsions occur in the same direction.10  

5- Practice, Practice, Practice: The best way to minimize errors is through experience, so scan lots of normal anatomy. The more scans you do, the better you will be able to differentiate abnormal from normal, even when you may not be sure exactly what the abnormality is. An image library of normal and abnormal scans helps immensely, so check out our library of cases on www.epmonthly.com

 

Teresa Wu (@TeresaWuMD) is an Associate Prof. and Simulation Curriculum Director at the U of A-College of Medicine-Phoenix. She is the Director of the Ultrasound Program & Fellowships for the Maricopa EM Program and the creator of SonoSupport. www.SonoSupport.com 
Brady Pregerson (@TheSafetyDoc) manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. For more info visit EMresource.org.

References

1. Wittenberg AF, Tobias T, Rzeszotarski M, Minotti AJ. Sonography of the acute scrotum: the four T’s of testicular imaging. Current Problems in Diagnostic Radiology.2006;35:12-21.

2. Blaivas M, Brannam L. Testicular ultrasound. Emergency Medicine Clinics of North America. 2004;22:723-748.

3. Stehr M, Boehm R. Critical validation of color Doppler ultrasound in diagnostics of acute scrotum in children. European Journal of Pediatric Surgery. 2003;13:386-392.

4. Dogra VS, Bhatt S. Acute painful scrotum. Radiology Clinics of North America. 2004;42:349-363.

5. Khadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. 1998;102(1):73-76.

6. Dogra VS, Gottlieb RH, Oka M, et.al. Sonography of the scrotum. Radiology. 2003;227:18-36.

7. Blaivas M, Batts M, Lambert M. Ultrasonographic diagnosis of testicular torsion by emergency physicians. American Journal of Emergency Medicine. 2000;18(2):198-200.

8. Schultz KE, Walker J. Testicular torsion in undescended testes. Annals of Emergency Medicine. 1984;13(7):567-569.

9. Patriquin HB, Yazbeck S, Trinh B, et al. Testicular torsion in infants and children: diagnosis with Doppler sonography. Radiology. 1993;188:781-785.

10. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: direction, degree, duration and disinformation. The Journal of Urology. 2003;169:663-665. 

 

 

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